YIJOM-4439; No of Pages 7

Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx

https://doi.org/10.1016/j.ijom.2020.05.007, available online at https://www.sciencedirect.com

Clinical Paper
Head and Neck Oncology

Navigation-guided core needle J.-H. Zhu, R. Yang, Y.-X. Guo,

J. Wang, X.-J. Liua, C.-B. Guoa
Department of Oral and Maxillofacial Surgery,

biopsy for skull base and Peking University School and Hospital of
Stomatology, National Engineering
Laboratory for Digital and Material
Technology of Stomatology, Beijing Key

parapharyngeal lesions: Laboratory of Digital Stomatology, Haidian

District, Beijing, PR China

a five-year experience
J.-H. Zhu, R. Yang, Y.-X. Guo, J. Wang, X.-J. Liu, C.-B. Guo: Navigation-guided core
needle biopsy for skull base and parapharyngeal lesions: a five-year experience. Int. J.
Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2020 Published by Elsevier Ltd on
behalf of International Association of Oral and Maxillofacial Surgeons.

Abstract. The aim of this study was to evaluate the diagnostic accuracy of navigation-
guided core needle biopsy for skull base and parapharyngeal lesions. Twenty
patients with skull base and parapharyngeal lesions were included in this study. The
preoperative design and intraoperative real-time image guiding was done using an
optical navigation system. A spring-loaded semi-automatic biopsy gun and biopsy
needle were used for specimen harvesting. Accuracy was established on the basis of
the postoperative pathology. All patients underwent needle biopsy successfully
without any immediate or delayed complications. The subzygomatic approach was
adopted in all cases. The number of passes ranged from three to five. The diagnostic Key words: core needle biopsy; skull base;
accuracy was 90% (18/20). Navigation-guided core needle biopsy offers an easy tumour; navigation.
approach for the diagnosis of skull base and parapharyngeal lesions, with a high
yield of specimens and good patient tolerance. Accepted for publication 13 May 2020

Lesions arising from the skull base biopsy would not be greatly different from and impaired observation of the complex
and parapharyngeal space are clinically those of a radical resection. Besides, neurovascular structures. Some reports
rare and their management is highly this would require general anaesthesia have described computed tomography
challenging. Conventionally, preoperative and would leave a surgical wound, also (CT)-guided core biopsy for skull base
pathological diagnosis remains a standard restricting its application in certain lesions3,4; however, the additional risk
requirement for better counselling and population groups. of radiation exposure for the surgeon
therapy. With a sufficient amount of spec- Although ultrasound-guided core nee- and the patient is not negligible. Magnetic
imen obtained by open biopsy, the pathol- dle biopsy (CNB) is recommended as an resonance imaging (MRI)-guided biopsy
ogist will be able to diagnose such lesions excellent technique in the diagnosis of for head and neck masses is not in
easily. However, because of the deep lo- cervicofacial masses because of its sim-
cation and difficult surgical approach for plicity, safety, and minimally invasive a
Chuan-Bin Guo and Xiao-Jing Liu made
the skull base region, the inherent risks nature1,2, it is not feasible for the skull equal intellectual contributions to the manu-
and difficulties of performing an open base region due to the osseous intervention script.

0901-5027/000001+07 ã 2020 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.

Please cite this article in press as: Zhu JH, et al. Navigation-guided core needle biopsy for skull base and parapharyngeal lesions: a five-
year experience, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.05.007
YIJOM-4439; No of Pages 7

2 Zhu et al.

widespread use because of the confined

space configuration, expensive cost, and
the need for MRI-compatible needles4.
The incomparable advantage of image-
guided navigation is the correspondence
between the surgical field and preopera-
tive planning images, which can provide
the possibility of real-time adaptation of
the needle trajectory and recognition of
the accurate location of the needle with
simultaneous three-dimensional (3D)
imaging of the vascular and bony struc-
tures surrounding the primary tumour.
Furthermore, the procedure is free of
intraoperative radiation exposure. Despite
the accuracy and efficacy of various CNB
procedures for head and neck lesions
being described extensively in the
literature1–3,5–7, the diagnostic utility of
the technique guided by optical navigation
has not yet been reported. This study was
performed to present the authors’ optimal
procedures for navigation-guided CNB for
skull base and parapharyngeal lesions and
to determine the diagnostic accuracy.

Materials and method

Patients
Twenty patients who underwent navigation-
Fig. 1. Overview of the biopsy equipment. (a) The navigation equipment accessories including
guided CNB between December 2013 and a headband with reference unit, two reference arrays, a pointer, and an instrument calibration
December 2018 were enrolled in this study. matrix. (b) The biopsy gun with needle.
Each patient was informed of the risks and
consented to the procedure. This study was
approved by the local institutional review
were transferred to the computer console according to imaging manifestations and
board. The medical records of all of these
in DICOM format (Digital Imaging clinical symptoms. An adjacent point at
patients were reviewed retrospectively.
and Communications in Medicine). The the boundary between the tumour and adja-
There were seven male patients and 13
CT scan included the area from the cal- cent tissues was chosen as the shooting
female patients, with a mean age of 50 years
varium to the clavicle to avoid missing point with a 15 or 22-mm shooting distance.
(range 12–78 years). Accuracy was assessed
any intracranial or external tumour The throw distance depends on the dimen-
based on the final pathology results after
boundaries. The forehead and nasal tip sion of the target, strictly keeping the speci-
surgical excision.
were also included during the scanning men notch within the tumour without
process in order to ensure the success of passing through the tumour margin. An
Biopsy platform the patient’s surface registration. optimal trajectory path was chosen based
on the judgement of the lowest possibility of
The Kolibri optical navigation system (Brain-
injury to the adjacent structures, shortest
lab AG, Feldkirchen, Germany) is composed Preoperative design
puncture distance, appropriate distance
of a dedicated computer workstation, an in-
All DICOM data were transferred to iPlan away from well-known vessels, and avoid-
frared camera, and other equipment accesso-
CMF 3.0 software (Brainlab AG, Feld- ance of the barrier structures (Fig. 2). The
ries (Fig. 1a). A spring-loaded semi-automatic
kirchen, Germany). The craniofacial skele- trajectory at the skin surface was set as the
biopsy gun (Bard Magnum; Bard Inc., Cov-
ton and skin were segmented automatically puncture point. The entire plan was saved
ington, GA, USA) and 14–18-gauge side-
after selection of the corresponding inher- and exported to the navigation workstation
notch biopsy needle with a variable needle
ent thresholds. The vessels, mainly the in the operating room.
throw (forward feed, 15 or 22 mm) (Bard
carotid artery and jugular vein, were seg-
Peripheral Vascular Inc., Tempe, AZ, USA)
mented via manual tracing methods using
were used for specimen collection (Fig. 1b). Patients and instrument registration
the enhanced CT images. The boundaries of
the tumour were carefully identified by at A non-invasive reference headband was
Workflow least two experienced surgeons, and manual used to rigidly fix the reference base in the
segmentation was subsequently performed. forehead area, in order to make the refer-
Data acquisition
3D reconstruction was applied for each ence base with reference array stable. The
Data acquisition was done through segmented object (Fig. 2). The optimal area rigidly fixed dynamic registration frame
enhanced CT with/without MRI data. for pathological examination was deter- could track the position of the head in real
The CT data (slice thickness 0.75 mm) mined and marked as the target specimen time, such that immediate compensation

Please cite this article in press as: Zhu JH, et al. Navigation-guided core needle biopsy for skull base and parapharyngeal lesions: a five-
year experience, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.05.007
YIJOM-4439; No of Pages 7

Navigation-guided core needle biopsy 3

Postoperative management
All specimens obtained were immediately
evaluated by macroscopic inspection to check
the adequacy of the material. If the specimen
was equivocal, frozen section examination
was suggested for quality check. If the histo-
logical results of frozen sections suggested
normal tissues or were not consistent with the
preliminary clinical diagnosis, repeated
procedures were performed to obtain more
specimens. Generally, three to five pieces of
specimen were harvested for each patient at
one time. The specimens were fixed in 10%
formalin as soon as possible and sent for
routine pathological examination.
When the biopsy was finished, the small
Fig. 2. Planning of the needle trajectory (blue line), with the segmented tumour (purple colour),
jugular vein (blue colour), and carotid artery (red colour).
puncture wound was manually compressed
for 5 minutes and subsequently bandaged
with a sterile dressing. All patients were
observed intensively for 1 hour, with special
for head movements could be made for the Needle biopsy
consideration for delayed haematoma or
needle trajectory without the necessity for
central neural damage. Oral antibiotics were
re-registration. If the reference headband The puncture point was marked on the
given twice on the day of the operation.
loosened during the procedure, then re- skin under the guidance of the navigation
registration was necessary. A non-touch pointer. Local anaesthesia was then ap-
scan was done in the forehead and zygo- plied around the marker point. Under the Results
matic area to align the patient’s face in- real-time image guidance, the biopsy nee-
dle was directed in the designed trajectory All of the patients underwent needle biopsy
formation with imaging data of the
and carefully pushed forward until the tip successfully without any immediate or
navigation plan. The registration accuracy
of the needle arrived at the shooting point. delayed serious complications, such as hae-
was double-checked manually before
With the guidance of the virtual overshot matoma, trismus, or severe pain. The mild
being accepted. Another reference array
tip, the direction was double-checked to swelling and discomfort usually disappeared
was aligned to the spring-loaded semi-
confirm that the tip of the needle could get within 3–4 days post biopsy surgery. The
automatic biopsy gun. The distance from
the specimen as planned (Fig. 4). After the subzygomatic approach was adopted in all
the needle tip to the reference array and
spring was released, the inner channelled cases. The number of specimen pieces
the diameter of the needle were measured
needle was advanced into the lesion to cut obtained ranged from three to five. The diag-
and recorded by an instrument calibration
and withdraw the specimen back into the nostic accuracy was 90% (18/20) based on
matrix for registration (Fig. 3). Once
outer cylindrical cuff. The needle was then these 20 cases (Table 1). Regarding the post-
the process was done, the registration
withdrawn and the specimen was released operative pathology, two biopsies were not
accuracy of the needle was confirmed
from the needle notch. consistent. One patient (case 2) was reported
for real-time navigation on the screen.
to have a cystic neoplasm, but the final
diagnosis following surgical resection was
vascular malformations. The lesion in the
other patient (case 16) was located in the
pterygopalatine fossa and maxillary sinus
(Fig. 5), and was primarily diagnosed as
chronic inflammation by CNB. The trismus
had not improved after 1 week of anti-
inflammatory therapy and exploratory
surgery was subsequently performed for
biopsy. The final diagnosis proved to be
poorly differentiated mucoepidermoid carci-
noma and definitive surgery and postopera-
tive adjuvant radiotherapy were subsequently
performed. The treatment of these two
patients was not adversely affected by these
diagnostic issues. The patient with the malig-
nancy was well at the 2-year follow-up.

Discussion
Incisional biopsy is the standard method
for the diagnosis of various tumours in
Fig. 3. Patient and instrument registration. clinical practice. However, it is not always

Please cite this article in press as: Zhu JH, et al. Navigation-guided core needle biopsy for skull base and parapharyngeal lesions: a five-
year experience, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.05.007
YIJOM-4439; No of Pages 7

4 Zhu et al.

Fig. 4. Puncture guided by navigation in real time. (a) Needle pushed forward into the soft tissues. (b) Guided to the puncture point. (c) Guided to
the shooting point.

Table 1. Results of core needle biopsy guided by navigation.

Patient Age Histological diagnosis Needle
number (years) Sex Location Frozen section from core needle biopsy passes Postoperative diagnosis
1 52 F Parapharyngeal space Neurogenic tumour Schwannoma 3 Schwannoma
2 12 M Lateral skull base - No tumour seen 4 Vascular malformations
3 48 F Pterygopalatine fossa Adenoid cystic Adenoid cystic 4 Adenoid cystic
carcinoma carcinoma carcinoma
4 70 M Parapharyngeal space Adenogenous carcinoma Poorly differentiated 4 Poorly differentiated
adenocarcinoma adenocarcinoma
5 78 M Lateral skull base Epithelial neoplasm Epithelial-myoepithelial 3 Epithelial-myoepithelial
carcinoma carcinoma
6 52 M Parapharyngeal space Adenogenous neoplasm Pleomorphic adenoma 3 Pleomorphic adenoma
7 57 F Parapharyngeal space Adenogenous neoplasm Pleomorphic adenoma 5 Pleomorphic adenoma
8 53 F Parapharyngeal space Mucoepidermoid Mucoepidermoid 4 Moderately
carcinoma carcinoma differentiated
mucoepidermoid
carcinoma
9 47 F Lateral skull base Osteogenic tumour Tendon sheath giant cell 4 Tendon sheath giant cell
tumour tumour
10 25 F Lateral skull base Chondrogenic tumour Chondrogenic tumour 4 Chondroma
11 51 M Lateral skull base Chronic inflammation of Chronic inflammation of 5 Myositis ossificans
muscle tissue muscle tissue with
fibrosis and ossification
12 33 F Parapharyngeal space Pleomorphic adenoma Pleomorphic adenoma 3 Pleomorphic adenoma
13 43 F Parapharyngeal space Adenogenous tumour Acinic cell carcinoma 4 Acinic cell carcinoma
14 50 F Lateral skull base Fibrous tissues Fibrous tissues and 5 Mixed vascular
dilated lymph vessels, lymphatic malformation
likely to be lymphatic
malformation
15 48 M Lateral skull base Fibrogenesis Fibrolipoma 3 Fibrolipoma
16 60 F Pterygopalatine fossa Chronic inflammation of Chronic inflammation of 5 Poorly differentiated
fibrous tissue muscle and fibrous mucoepidermoid
tissues carcinoma
17 60 F Parapharyngeal space Neurogenic tumour Schwannoma 3 Schwannoma
18 62 F Parapharyngeal space Pleomorphic adenoma Pleomorphic adenoma 3 Pleomorphic adenoma
19 62 F Lateral skull base Poorly differentiated Adenogenic carcinoma 5 Non-specific
malignant tumour adenocarcinoma
20 36 M Lateral skull base Neurogenic tumour Schwannoma 3 Schwannoma
F, female; M, male.

Please cite this article in press as: Zhu JH, et al. Navigation-guided core needle biopsy for skull base and parapharyngeal lesions: a five-
year experience, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.05.007
YIJOM-4439; No of Pages 7

Navigation-guided core needle biopsy 5

may occur up to 20 years following sali-

vary biopsy14. Although it does not affect
the prognosis as long as the disseminated
tumour cells can be removed surgically or
destroyed by chemoradiotherapy2, the
risk should be minimized. Excision of
the needle tract is often performed at the
time of surgery, but this is not routinely
required14–16.
The bleeding risk is another significant
complication2. A major disadvantage of
the side-cutting needle is that the stylet
may protrude outside the target to accom-
modate the specimen notch in the optimal
position for small lesions, which will
increase the risk of endangering the adja-
cent structures, particularly when the
Fig. 5. CT of a 60-year-old female (case 16) with a left pterygopalatine fossa and maxillary
sinus lesion. The pre-procedural enhanced CT showed a diffuse lesion (arrow). The biopsy
lesions are very close to the major neck
showed chronic inflammation of muscle and fibrous tissues. A poorly differentiated mucoe- vessels7. Walker et al.16 reported the
pidermoid carcinoma was diagnosed by surgical resection. case of a patient with an oral haemorrhage
at 3 months post biopsy, caused by
internal maxillary artery pseudoaneurysm
optimal for head and neck tumours With the real-time navigation-guided sys- formation after CT-guided biopsy in the
because of its inherent disadvantages. tem, the needle tip can be guided precisely masticator space. In the present study, the
Incisional biopsy is considered the last to the shooting point within the normal safety of the shooting distance was well
resort for patients in whom other methods tissues under 3D visualization as designed managed both in the preoperative design
have failed repeatedly or those warranting preoperatively, avoiding any stabbing into and in the performance of the intraopera-
resection at the time of obtaining diagnos- the mass harbouring the abnormality. tive navigation. Owing to the 1.5 or 2.5 cm
tic specimens8. Fine-needle aspiration Fortunately, reports of tumour seeding protrusion distance, the needle biopsy of
(FNA) is an effective technique for diag- after CNB in the head and neck region are tumours with a diameter below 1.5 cm is
nosis that avoids an open wound and is rare10. Ferreira et al.5 evaluated a total of prohibited.
commonly used in the clinical setting for 36 patients who underwent CNB for the The needle approach is another impor-
head and neck lesions, especially for the diagnosis of tumours in the head and neck tant factor. The subzygomatic approach is
diagnosis of malignant tumours5,6. How- region over a period of 3 years, and this suitable for the biopsy of lesions in the
ever, it depends highly on the cytopathol- complication was not observed in any infratemporal fossa and in the masticator,
ogist’s experience, because only cells are patient. Novoa et al.2 reported only one parapharyngeal, and retropharyngeal
harvested for evaluation. As such, FNA case concerning the dissemination of tu- spaces17. Although it carries the risk of
has a high false-negative rate and is not mour cells after reviewing 1291 CNB in injury to the pterygoid venous plexus, this
definitive for the final diagnosis6,9. the head and neck region. In fact, the related injury has not been reported17.
Compared with open biopsy and FNA, identification of true tumour seeding and There are also other needle approaches
CNB results in less trauma without a local recurrence during follow-up after a such as the retromandibular approach,
postoperative scar and obtains more suffi- previous needle biopsy is difficult when with the risk of injury to the external
cient materials for immunohistochemical this happens in the organ parenchyma10. carotid artery, retromandibular vein, and
staining, which helps in determining the It is generally believed that tumour facial nerves3. The selection of the needle
clinical treatment; this is particularly seeding is related to the needle diameter, approach is based on the location of the
useful for patients who have undergone the nature of the tumour, and the anatomi- lesion and individual anatomical relation-
previous surgery and irradiation with cal site biopsied2,10,11. 18/20-gauge nee- ships17. However, what makes navigation-
severe fibrosis or a granulomatous re- dles are suitable for head and neck tumour guided CNB different is that the use of
sponse2,3. Nevertheless, some physicians needle biopsy, providing acceptable path- enhanced CT scanning combined with/
are still reluctant to perform CNB in con- ological information and resulting in few without MRI is very helpful in planning
sideration of the possible complications, complications6,12. Although the larger- a safer trajectory, as the bony structures,
mainly tumour seeding2. Tumour seeding sized needle theoretically increases the soft tissues, and major vessels are precise-
theoretically occurs when the malignant possibility of procedure-related complica- ly segmented. In the present study, the
cells are disseminated along the needle tions, there is no evidence that tumour surgeon could more confidently identify
tract. However, the co-axial technique, seeding is more common with larger the vessels with the use of the intraoper-
as used in the present study, can isolate needles13. However, for patients whose ative real-time image navigation, thereby
the specimen from the needle tract by lesions are clinically suspected to be avoiding vessel injury. As a result, no
keeping the sample enclosed within the benign neoplasms, mainly pleomorphic major bleeding requiring hospital admis-
inner needle notch when the cannula is adenoma, biopsies should be performed sion occurred after CNB in this study.
withdrawn, thereby reducing the risk of with an 18-gauge needle. Salivary tumour To achieve a definitive diagnosis, it is
tumour seeding10. The key point of this seeding in patients who have undergone important to evaluate the tumour boundary
technique is to push the needle forward to CNB with an 18-gauge needle has never with surrounding tissues14. Although a
the boundary between the tumour and been reported6, but a longer follow-up is part of the boundary may be included in
adjacent tissues, within the normal tissues. still needed in view of the fact that this the ultrasound-guided core biopsy, this is

Please cite this article in press as: Zhu JH, et al. Navigation-guided core needle biopsy for skull base and parapharyngeal lesions: a five-
year experience, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.05.007
YIJOM-4439; No of Pages 7

6 Zhu et al.

not always reliable, which may result in 18-gauge needle. There is also a case approach, high yield of specimens, and
diagnostic failure in some cases14. The report presenting three cases in which good patient tolerance.
advantage of the navigation-guided CNB FNA of deep-seated neck masses close
is that the segmented 3D images give the to the mucosal surface of the oropharynx
surgeons visual information about the was performed successfully under Funding
location and size of the lesion and the intraoral ultrasound guidance18. This study was supported by the Intergov-
adjacent structures, while different axial Connor and Chaudhary3 reported the ernmental International Cooperation
two-dimensional images simultaneously diagnostic accuracy of CT-guided CNB Project of the National Key R & D Plan
give more detailed information. The of deep face and skull-base lesions to be (grant number 2017YFE0124500), the
surgeon can then select a more direct 87% (13 of 15) for all samples and 93% Capital Featured Clinical Application
trajectory or make a flexible path to ma- (13 of 14) for those with adequate histol- Research Project of Beijing Municipal
nipulate the biopsy needle exactly towards ogy. In the present study, the diagnostic Science and Technology Commission
the lesion in real time. Furthermore, accuracy was 90% (18/20) for all patients, (grant number Z161100000516043), and
with the information in the preoperative without intraoperative radiation exposure. the National Key R&D Program of China
images, the most representative or suffi- Furthermore, for those patients receiving (grant number 2019YFB1311304).
ciently characteristic specimen can be non-surgical treatment or palliative
targeted in advance and harvested for therapy, navigation-guided CNB has the
pathological diagnosis. This advantage potential benefit of providing a fast and Competing interests
gives the surgeon a greater opportunity accurate diagnosis without any surgical
to make a correct final diagnosis. intervention, particularly for the verifica- The authors have no relevant conflicts of
However, in this study, there was still a tion of primary tumour recurrence. interest to disclose.
mucoepidermoid carcinoma case for Nevertheless, navigation-guided needle
which the most representative specimen biopsy has its limitations. Firstly, this tech- Ethical approval
was not obtained, due to its obscure nique is not appropriate for superficial and
and diffuse character shown in the pter- flexible lesions. The pressure applied This study was approved by the Institu-
ygopalatine fossa and maxillary sinus. In during the puncture process will make the tional Review Board of Peking University
this particular case, chronic inflammation soft tissues and the lesion drift, thus the School and Hospital of Stomatology
of the muscle and fibrous tissues simulta- navigation images will fail to represent the (PKUSSIRB-2013039).
neously accompanied the lesion, which real anatomical structures on screen. Fur-
may have been due to peri-tumoural thermore, the indication for needle biopsy
reactive changes. The inaccurate needle should be considered carefully in the case of Patient consent
trajectory and lack of a sufficient charac- a suspected cystic lesion. In the cystic Patient consent was obtained.
teristic specimen may have been the main misdiagnosis case in the present study,
factors responsible for this misdiagnosis. the threshold was similar to that for a solid
Hence an experienced surgeon will play a lesion in the preoperative CT images, but no References
significantly important role in the planning specimen was harvested during needle 1. Pfeiffer J, Kayser G, Technau-Ihling K, Boe-
of the needle trajectory. biopsy. An open surgery biopsy was subse- deker CC, Ridder GJ. Ultrasound-guided
Due to the potential problems of quently performed and this was revealed to core-needle biopsy in the diagnosis of head
intraoperative frozen sections, a definitive be a cystic lesion with thick liquid. In fact, if and neck masses: indications, technique, and
diagnosis may not be empirically provided a cystic lesion is identified by radiological results. Head Neck 2007;29:1033–40.
by some pathologists, especially those examination, an aspiration needle is needed 2. Novoa E, Gürtler N, Arnoux A, Kraft M.
working outside of specialist units, in the for cystic fluid examination. As indicated Role of ultrasound-guided core-needle biop-
face of a challenging diagnostic area.14 For by the two inconsistent cases, it should be sy in the assessment of head and neck
this reason, frozen sections cannot usually emphasized that excisional biopsy cannot lesions: a meta-analysis and systematic re-
be used to dictate treatment without the be totally replaced in spite of the unique view of the literature. Head Neck 2012;34:
final histology. Unsurprisingly, there was advantages of navigation-guided CNB. 1497–503.
a disparity between intraoperative Thus, rigorous indication criteria should 3. Connor SEJ, Chaudhary N. CT-guided per-
frozen section and CNB histology in case still be applied. cutaneous core biopsy of deep face and
5 (epithelial neoplasm vs epithelial- This study proved the feasibility of skull-base lesions. Clin Radiol 2008;63:
myoepithelial carcinoma) and case 13 (ade- navigation-guided core needle biopsy for 986–94.
nogenous tumour vs acinic cell carcinoma) skull base tumours, although the sample 4. Gupta S, Henningsen JA, Wallace MJ, Mad-
off DC, Morello Jr FA, Ahrar K, Murthy R,
in this study. Nevertheless, intraoperative size was limited and more evidence of the
Hicks ME. Percutaneous biopsy of head and
frozen section was still used as a comple- advantages and disadvantages is needed,
neck lesions with CT guidance: various
mentary test to improve the diagnostic such as tumour recurrence. This evidence
approaches and relevant anatomic and
accuracy in the case of a non-diagnostic should be confirmed in the future before technical considerations. Radiographics
or equivocal CNB in this study. the technique becomes widely accepted 2007;27:371–90.
The application of FNA in head and and clinical guidelines are developed. 5. Ferreira VH, Sassi LM, Zanicotti RT, Ramos
neck lesions is frequently reported, but In conclusion, assisted by advanced GH, Jung JE, Schussel JL. Core needle
only a few published series have evaluated navigation, core needle biopsy offers a biopsy in the diagnosis of head and neck
its use for skull base and parapharyngeal safe, effective, and minimally invasive lesions: a retrospective study of 3 years. Eur
lesions. Yousem et al.8 reported 90% ac- way for making an accurate diagnosis. It Arch Otorhinolaryngol 2016;273:1–4.
curacy (18/20) for CT-guided transcutane- is suggested as one of the important 6. Chen CN, Yang TL. Application of ultra-
ous aspirations of parapharyngeal and diagnostic tools for skull base and para- sound-guided core biopsy in head and neck.
skull base masses with the help of an pharyngeal space lesions, with an easy J Med Ultrasound 2014;22:133–9.

Please cite this article in press as: Zhu JH, et al. Navigation-guided core needle biopsy for skull base and parapharyngeal lesions: a five-
year experience, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.05.007
YIJOM-4439; No of Pages 7

Navigation-guided core needle biopsy 7

7. Yuen HY, Lee Y, Bhatia K, Wong KT, Ahuja guided core biopsy and open biopsy techni- ance. AJNR Am J Neuroradiol 2006;27:
AT. Use of end-cutting needles in ultra- ques. Adv Otorhinolaryngol 2016;78:39–45. 1654–7.
sound-guided biopsy of neck lesions. Eur 14. Berger-Richardson D, Swallow CJ. Needle
Radiol 2012;22:832–6. tract seeding after percutaneous biopsy of Address:
8. Yousem DM, Sack MJ, Hayden RE, Wein- sarcoma: risk/benefit considerations. Cancer Chuan-Bin Guo
stein GS. Computed tomography-guided 2017;123:560. Department of Oral and Maxillofacial
aspirations of parapharyngeal and skull base 15. Kraft M, Laeng H, Schmuziger N, Arnoux A, Surgery
masses. Skull Base Surg 1995;5:131–6. Gürtler N. Comparison of ultrasound-guided National Engineering Laboratory for Digital
9. Sebire NJ, Roebuck DJ. Pathological diag- core-needle biopsy and fine-needle aspira- and Material Technology of Stomatology
nosis of paediatric tumours from image- tion in the assessment of head and neck Beijing Key Laboratory of Digital
Stomatology
guided needle core biopsies: a systematic lesions. Head Neck 2010;30:1457–63.
Peking University School and Hospital of
review. Pediatr Radiol 2006;36:426–31. 16. Walker AT, Chaloupka JC, Putman CM,
Stomatology
10. Robertson EG, Baxter G. Tumour seeding Abrahams JJ, Ross DA. Sentinel transoral
No. 22 Zhongguancun South Avenue
following percutaneous needle biopsy: the hemorrhage from a pseudoaneurysm of the Haidian District
real story! Clin Radiol 2011;66:1007–14. internal maxillary artery: a complication of Beijing 100081
11. Pratap R, Qayyum AN, Jani P, Berman L. CT-guided biopsy of the masticator space. PR China
Ultrasound-guided core needle biopsy of AJNR Am J Neuroradiol 1996;17:377–81. Tel.: +86 10 82195295.
parotid gland swellings. J Laryngol Otol 17. Wu EH, Chen YL, Toh CH, Ko SF, Lin YC, Fax: +86 10 62173402
2009;123:449. Ng SH. CT-guided core needle biopsy of [email protected],
12. Jens P, Lis K, Ridder GJ. Minimal-invasive deep suprahyoid head and neck lesions in [email protected],
core needle biopsy of head and neck malig- untreated patients. Interv Neuroradiol [email protected],
nancies: clinical evaluation for radiation on- 2013;19:365–9. [email protected],
cology. Radiother Oncol 2009;90:202–7. 18. Wong KT, Tsang RK, Tse GM, Yuen EH, [email protected],
13. Howlett DC, Triantafyllou A. Evaluation: Ahuja AT. Biopsy of deep-seated head and [email protected]
fine needle aspiration cytology, ultrasound- neck lesions under intraoral ultrasound guid-

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year experience, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.05.007